Do you wake up feeling unrested in the morning? Have you experienced morning headaches, or been told that you snore at night? Do you feel fatigued or sleepy during the day, despite a full night of sleep?
These symptoms can result from many things, but one common, under-recognized cause involves problems with breathing during sleep. This is known as sleep apnea. Fortunately, sleep apnea can be diagnosed and treated to improve the symptoms and overall quality of life.
What is Obstructive Sleep Apnea?
Normal breathing involves the exchange of air between the environment, the lungs, and the blood. When we inhale oxygen from the air around us, it travels down our airway into the lungs. From there, it dissolves into the blood for delivery to our vital organs. At the same time, carbon dioxide (which is a byproduct of our normal body processes) is removed from the blood by the lungs and is exhaled out of the body.
In people with obstructive sleep apnea, the airway is repeatedly blocked (termed “apnea”) or narrowed (termed “hypopnea”) by surrounding tissues. This causes brief episodes of reduced breathing while asleep – often without realizing it. For the purposes of this article, the phrase sleep apnea will refer only to this obstructive type (OSA). There are other types of sleep apnea that we will not discuss here.
The tissues and structures around the airway that are involved in this condition include the back of the tongue, the soft palate, the muscles surrounding the back of the throat, the area behind the nose, and the muscles of the upper neck. Relaxation of the upper airway muscles and tissues in sleep can lead to airway collapse, snoring, and choking noises, although these are not always present in people with sleep apnea. Snoring is caused by tissues of the airway vibrating against each other causing sound.
When less air gets into the lungs due to these repeated blockages, less oxygen gets delivered to important organs like the brain. These obstructions also reduce the ability to fully exhale. This can cause carbon dioxide to build up in the blood, which is associated with morning headaches and other health problems.
Airway blockages can last for 10 seconds or longer and can result in significant decreases in oxygen delivery to the brain and other organs. These drops in oxygen can cause awakening and gasping for air. Episodes can occur repeatedly during sleep, anywhere from a few times a night to hundreds of times per hour. They may be so brief that the person does not realize it but are still enough to disrupt the progression through the typical sleep stages. This can make a full night of sleep less restful and restorative.
Sleep involves a sequence of stages that we normally cycle through multiple times per night. Sleep apnea can happen during any of those stages, but commonly occurs during a period of deep sleep known as Rapid Eye Movement (REM). We experience some muscle paralysis during rapid eye movement sleep, which is normal. This paralysis also affects the muscles and tissues around the airway, increasing the chances of obstructed breathing. Arousals or awakenings due to lack of air cause sleep cycles to end early and return to lighter stages of sleep. People with obstructive sleep apnea spend less time in the deeper stages of sleep. This leads to feeling poorly and unrested upon waking, even if the person spent enough total time asleep. Apnea-induced awakenings can also reduce total sleep time, another contributor to symptoms like tiredness the following day.
What are the risk factors for obstructive sleep apnea?
Certain anatomical characteristics are associated with an increased risk of obstructive sleep apnea. They include:
- Neck circumference larger than 17 inches (43 cm) for men and 16 inches (40.5 cm) for women
- Structural changes that prevent smooth airflow through the nose, such as a deviated septum
- Certain variations of facial anatomy such as a short/recessed jaw, or an enlarged tongue or tonsils
Weight: A body mass index (BMI) exceeding 35 confers a significantly increased risk of obstructive sleep apnea, although people with a BMI below this level can still have the condition.
Age & Sex: The highest incidence of sleep apnea occurs beginning in middle age. Men are at higher risk than women, at least until women go through menopause.
High Blood Pressure: those with obstructive sleep apnea are more likely to have high blood pressure. This is because untreated sleep apnea itself can cause high blood pressure.
Family history: If one or more of your parents have sleep apnea, that increases your risk for developing it. You inherit some of your facial and other anatomical features.
Drugs & Medicines: Other things that can exacerbate sleep apnea include alcohol use and other sedating drugs or medicines. These can cause increased relaxation of the tissues that contribute to airway collapse, and also make the brain less sensitive to the signals that would normally cause someone to wake up and breathe.
Why do we care about obstructive sleep apnea?
Untreated obstructive sleep apnea can have multiple harmful effects. It can impact quality of life due to unrefreshing sleep, frequent nighttime urination, daytime fatigue, memory difficulties, sexual problems like erectile dysfunction or decreased libido, and mood disorders such as depression. Daytime sleepiness is also associated with other risks such as a higher rate of traffic accidents. Note that other conditions can also cause many of these symptoms, so they should not be assumed to be due to sleep apnea without evaluation by a doctor.
Untreated sleep apnea that is moderate to severe increases the risk of cardiovascular problems like atrial fibrillation, congestive heart failure, coronary artery disease, and stroke. It can also cause high blood pressure, worsen blood sugar control, and increase the risk of obesity.
A particularly common concern among men in the lifting world is testosterone. We frequently consult with men who feel fatigued or who are not making their desired rate of progress in the gym despite hard training. They may have even gotten their blood testosterone levels checked and found them to be low. In many of these situations, these individuals need to be screened for obstructive sleep apnea. This is because sleep apnea can contribute to nearly all of the same symptoms of low testosterone by itself, but it can also cause low testosterone too. In fact, clinical guidelines recommend against starting people on testosterone replacement therapy if they have untreated sleep apnea, due to complications that can occur. Before we recommend testosterone replacement therapy for men, we typically assess things like their waist circumference for excess body fat and diabetes risk, alcohol and opioid use, and their sleep – including the amount of sleep they get, the quality of that sleep, and their risk for sleep apnea.
How is obstructive sleep apnea diagnosed?
A conclusive diagnosis for sleep apnea requires some testing done in concert with a physician. However, a quick and useful to tool to determine if you might be at risk is the
STOP-BANG questionnaire. Ask the following questions. Each “yes” answer earns one point toward your score:
S – Do you snore loudly (louder than talking or loud enough to hear behind a closed door)?
T – Do you feel tired, fatigued or sleepy during the day?
O – Has anyone told you that you stop breathing at night?
P – Do you have (or are you being treated) for high blood pressure?
B – Is your Body Mass Index greater than 35?
A – Is your age greater than 50 years old?
N – Does your neck circumference exceed 40 cm?
G – Are you a male?
A total of 3 points or greater indicates a higher risk of sleep apnea, and further testing is recommended to confirm the diagnosis. There are a few ways to do this.
- In-Lab Polysomnography (PSG) – This is a traditional sleep test performed outside of your home and is the “gold standard” test for sleep apnea. You go to a clinic or hospital and spend the night in a sleep center with rooms specifically designed for sleep studies. A technician will attach sensors for brain wave activity, heart activity, blood oxygen levels, breathing effort, leg movement, and muscle tone. These are used to monitor your sleep overnight, measuring the number of apneas, hypopneas, oxygen levels, and many other things to make the diagnosis. In some cases where the diagnosis is immediately obvious, treatment for sleep apnea can be initiated in the same night.
- Home Sleep Test – this is a sleep test that is conducted in your home, without a hospital employee to assist or monitor you overnight. Data collection would include blood oxygen levels and breathing effort (using a chest or abdominal belt). Some home tests include positional monitoring devices. The information is collected and sent back to a doctor who interprets the results afterwards.
- Other methods can provide clues that suggest sleep apnea but cannot diagnose it definitively. For example, continuous oxygen monitoring in a hospitalized patient might reveal decreases in oxygen levels overnight. Other devices and “sleep trackers” that people use at home can provide other clues for sleep apnea but would still need formal home sleep testing or in-lab testing to prove.
What are the treatments for obstructive sleep apnea?
As with many treatments in healthcare, conservative treatments for obstructive sleep apnea include lifestyle modifications such as weight loss and treating nasal congestion and allergies. People should also minimize the use of alcohol and other sedating drugs or medications. Weight loss is a topic unto itself and is discussed more in our Health Priorities Article. Physical activity is important for supporting weight loss efforts. Please check out our Beginner Prescription for more on this. A weight reduction of 10% of a person’s body weight or greater can lead to substantial improvements in sleep apnea, blood pressure, and many other areas of health.
The details of more specific treatments for sleep apnea should be discussed with your doctor. As with all medical decisions, a person’s individual situation requires thoughtful attention, and we cannot make any definitive recommendations in an article. With that in mind, the most common medical interventions include:
- Positive airway pressure (PAP) machines: these involve wearing some form of a mask or device that applies a gentle pressure to keep the airways open all night. These have acronyms such as CPAP, APAP, or BiPAP, depending on how the device works.
- Oral appliance – these are devices inserted into the mouth at night that re-position the lower jaw forward to reduce the rate of blockages overnight.
- Surgery – there are multiple procedures that can be performed for sleep apnea, although these are usually reserved for more severe cases where people are unable to use positive airway pressure machines. These include operations on the nasal septum, removal of tonsils, adenoids, or other tissues of the soft palate, or implanting devices in the chest to monitor for apneas and uses electrical signal to the muscles of the throat/tongue.
Should I get evaluated for sleep apnea?
Sleep apnea affects an estimated 15-30% of men and 10-15% of women in North America, and well over 900 million people worldwide. It is under-diagnosed and contributes to many other health problems. It can make people feel badly during their waking hours. Almost all the treatments for the condition, except for surgery, are not very invasive and do not involve drugs. Treating sleep apnea can help with numerous underlying conditions. When you put these things together, it is definitely worth discussing your symptoms with your doctor. Evaluation is recommended if you experience:
- non-restorative sleep
- daytime tiredness despite a full night of sleep
- physical symptoms of snoring
- witnessed gasping for air or stopping breathing while asleep
- recently increased BMI, or a BMI above 35
- morning headaches
- a score of three of greater on the STOP BANG with daytime symptoms
- difficult to treat high blood pressure.
You should get screened if you have any of the above symptoms. If you have a family history of obstructive sleep apnea, mood changes, memory difficulties, sexual dysfunction, or concentration difficulties, those may also warrant screening. This gets complicated because other conditions and situations may be causing the above symptoms. Our advice is that you see your doctor to evaluate if there are other potential causes for these symptoms, in addition to sleep apnea. We wish you a good night’s sleep.
Thank you to Nate Gordon, MD for his assistance writing this article and Tom Campitelli for editing.